A neonate,18-day-old female baby presented with congenital scalp swelling and was evaluated by the neurosurgical team. Her mother belonged to a remote area where no prenatal ultrasonography was available; baby was delivered at a district hospital through LSCS. Scalp swelling progressively increased since birth. Complete physical examination of the baby revealed a congenital scalp swelling with no other associated congenital anomalies such as spine defect, limb defect; vertebral anal anomalies, trachea oesophageal anomalies, cardiac anomalies and renal anomalies. There was no hypertelorism or proptosis and fundus examination had no early signs of hydrocephalous. The swelling partially became lax when the patient was held erect and got tense on lying down the baby [Table/Fig-1].
As shown in picture [Table/Fig-1] a cystic swelling of the size 9×7 inches with a daughter cyst of size 4×3 inches was located in midline, midway between frontal and occipital region. Size of the head as per age was normal with no hydrocephalous and other congenital anomaly. Detailed neurological examination and other systemic examination revealed no significant associated anomalies. Swelling was transilluminent and partly filled by aberrant brain tissue. 3D CT SCAN head showed a focal defect involving high parietal bone with herniation of CSF filled sac and neural tissue through this defect suggestive of encephalocele. There was forced sutural separation in the midline and anterior fontanel was enlarged enormously due to the pedicle of the cyst [Table/Fig. 2, 3, 4, 5]
Excision and repair of the sac was done under general anaesthesia with prone position. Elliptical incision encircling the pedicel of the cyst was made and duramater was defined all around the sac. Sac was opened and about 800 cc dark brown fluid came out with pressure. Cyst wall was excised all around and aberrant atrophied brain tissue partially filling the cyst was excised. Superior sagittal sinus was aberrant, midline superior sagittal sinus could not be located during the surgical procedure, and probably it was obliterated or atrophied due to mass effect of tumor. Dural defect was meticulously repaired, to get a watertight closure. Child stood surgery well and post operatively child could move all four limbs without any gross neurological deficit. No ventilator support was needed post operatively. Post-operative recovery was uneventful till 4th postoperative day.